Provider Demographics
NPI:1558907519
Name:HOGAN, AMBER IMANI (PAC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:IMANI
Last Name:HOGAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:861 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7383
Mailing Address - Country:US
Mailing Address - Phone:810-953-0500
Mailing Address - Fax:810-953-0031
Practice Address - Street 1:861 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7383
Practice Address - Country:US
Practice Address - Phone:810-953-0500
Practice Address - Fax:810-953-0031
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13262OtherPA LICENSE
MI5601009493OtherPA LICENSE
MI5601009493OtherPA LICENSE